Managing Transition of Care for Patients: 5 Best Practices

The term transition of care (TOC) describes the set of actions taken by care providers, patients, and family members to ensure a safe and productive move from one healthcare situation to the next. Transitions have been identified as a particularly vulnerable time for patients, making TOC processes crucial to patient safety and wellbeing.

This often-weak link in the patient journey has been examined from different angles, across various care settings. For example, it’s estimated that 40% of patients are discharged from the hospital with labs pending, placing them at risk if the appropriate follow-up isn’t executed. In-hospital transfer processes can also be problematic, with one study finding that 46% of patients experienced a medication error when they were moved from the ICU to a non-ICU setting.

Researchers have found that inadequate management of care transitions results in $25 to 45 billion in unnecessary spending per year, primarily related to avoidable complications and readmissions. The mounting evidence of the dangers and costs involved in care transfers has initiated a lot of research into the topic.

In this guide, we’ll give you an overview of the three phases of the process. We’ll cover some of the prominent organizations that provide guidance about how to manage each phase, and discuss strategies for implementing evidence-based tactics. Our five best practices provide actionable steps for optimizing the transition phases at your facility.

What Is a Transition of Care?

Care transitions occur when patients move from one environment to another, or from one level of care to another. Transitions can happen within an organization (internally) or between a sending facility and a destination.

Example 1: A hospitalized patient is discharged and returns home.

Example 2: A pediatric patient with a chronic condition transitions to adult health services.

Key Steps in the Transition of Care Process

The TOC process is often described in three phases:

1. Pre-transition is a time for planning, patient education, and laying groundwork.
2. Transfer is when a provider handoff occurs, and the patient is moved (or care is transferred).
3. Post-transition is a time for follow-up care and re-assessment.

Why Is TOC Management Important?

Moving patients between facilities, units, or levels of care is a high-risk activity. Transitioning care involves many factors, all of which must be orchestrated properly in order for the move to be successful. When managed well, care is continuous and beneficial and patients have the resources they need for navigating their new situation. Optimal TOC processes can save facilities money by decreasing 30-day readmission rates and improving value-based care reimbursement margins.

What Happens When TOC Is Not Managed Properly?

Poorly managed transitions can cause patient harm. It’s estimated that 60% of medication errors occur during these times. Other risks to patients include:

• Development of avoidable complications.
• Inadequate follow-up care.
• Deterioration of a health condition.
• Adverse events (i.e. falls, development of pressure ulcers).
• Delayed treatments.
• Mortality.
• Readmission to an acute care setting.

Prominent TOC Models

Because transitions are a time of vulnerability for patients, multiple models have been developed and tested to improve the process. Here are three of the leading frameworks.

What Is Transitional Care Management (TCM)?

This is a program created by the Centers for Medicare and Medicaid Services (CMS) to help patients transition from inpatient care to their home or usual community setting (such as an assisted living facility). TCM services cover 30 days post-discharge and include:

• Early post-discharge contact from a designated provider.
• Medication management.
• Support.

The program introduced two Transitional Care Management codes that providers can use to bill for services. Providers typically choose between these CPT codes for transition of care services, depending on the exact timing and type of care provided.

Managing Transitions of Care: 5 Best Practices

Safe transitions rest on a foundation of coordination between many individuals. Here are five actions you can take to improve management of this complex process.

1. Identify Patients at Risk for Poor Transitions Early

Evidence-based TOC frameworks often incorporate screening tools. This is because screening patients to identify those who are high-risk is crucial to the pre-transition phase. By identifying these patients as soon as possible, key interventions can be initiated, such as:

• Involving a case manager, patient care coordinator, or transition coach.
• Patient teaching.
• Addressing deficits related to SDOH.
• Laying the groundwork for a safe discharge.

2. Use Standardized, Validated Tools

There’s been a great deal of research on care transitions, resulting in some excellent tools that can be used during the process. Encourage providers to incorporate research-backed tools, such as:

• National Transitions of Care Coalition (NTOCC) tools and resources.
• Screening and management tools available in market-leading EHRs.
• The LACE Index (used to predict post-discharge death or readmission).
• Got Transition’s tools and resources (used for transitioning a patient from pediatric to adult care).

3. Establish a Robust Medication Reconciliation Process

It’s estimated that 60% of medication errors occur during care transitions. Examine errors in this area to identify root causes, and implement corrections to improve your process. Create a workflow that involves the patient. Empower patients to speak up with questions and concerns about their current list of medications.

4. Make Data-Driven Refinements

Implement continuous quality improvement measures to refine your TOC system to better serve your patients. Small, incremental changes can make a big difference. Track quality metrics to assess the caliber of your transitions and identify the steps that need improvement. Examples of quality metrics related to TOC include 30-day readmission rates and patient satisfaction scores.

5. Use Top-of-License TOC Workflows

Transitioning a patient safely from one care situation to the next is resource-intensive. Look closely at your process to determine whether each professional involved is performing tasks that are at the top of their training and credentialing. For example, a CNA may be able to gather information for a TOC risk assessment screening, but they’re not licensed to conduct the related clinical assessment.

Discover More Healthcare Management Strategies

Exciting innovations are shaping healthcare delivery, including transition of care services. Want help staying current? Our expert-backed healthcare industry resources and guides synthesize the research for you, so you can focus on running your facility.